Kristine Ruggiero CPNP, MSN, RN Chapter 29 Alterations in Cellular Growth

Kristine Ruggiero CPNP, MSN, RN

Chapter 29

Alterations inCellular Growth

Differences between Pediatric and Adult presentation of Cancer

• Incidence of Cancer in Childhood:– Approximately 9,000 children diagnosed in

United States in 2003– Cancer is the leading cause of death for

children under age 15– In 2003, about 1,500 children died of cancer,

1/3rd from leukemia– Types of tumors vary by age and affect

survival rate

FIGURE 29–1 Percentage of primary tumors by site of origin for different age groups. Notice that in the early years of life, in addition to leukemia, cancers that derive from embryonic cells such as sympathetic nervous system (neuroblastoma) and eye (retinoblastoma) are common. As the child grows, lymphoma becomes more common in school years, and germ cell cancers of ovary and testes emerge as more common causes in teens.

Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Anatomy and Physiology of Pediatric Differences

• Immune system more immature in children – This affects how well body can defend itself– Nonspecific and specific cellular responses are

immature in infants and premies• Children are still growing and developing

– As a result, some cancers grow and progress more rapidly

– Apoptosis (programmed-cell death) not well-developed in young children

– Children more commonly present with metastases at time of dx than adults d/t the difficulty in recognizing s/sx of cancer (usually mistaken for childhood illness)

Differences between adults and children with cancer

• Childhood cancers respond better to chemotherapy

• Children tolerate chemotherapy better than adults

• Childhood survivors of cancer need to be monitored for late-effects and long-term side effects of cancer treatment– “Late-effects” clinics

Etiology and Pathophysiology

• Alterations in cellular growth occur in response to external and internal stimuli

• Neoplasms are caused by one or a combination of three factors;– External stimuli that cause genetic mutations– Innate immune system and gene

abnormalities– Chromosomal abnormalities

FIGURE 29–2 A protooncogene normally regulates cellular growth and development. When altered by a virus or other external cause, it can change to an oncogene, which allows unregulated genetic activity and tumor growth. Tumor-suppressor genes regulate the effects of oncogenes to decrease wildly proliferating cellular growth.




Clinical Manifestations

• Vary by type and location– Pain – Cachexia

• (syndrome characterized by anorexia, weight loss, anemia, asthenia (weakness) and early satiety)

– Anemia– Infections– Bruising– Neurologic symptoms– Palpable mass

Diagnostic Tests

• CBC• Bone marrow

aspiration• Bone marrow biopsy• Lumbar puncture• CXR

• Radiographic examination

• MRI • CTscan• US• Biopsy of Tumor• (See Table 29-2)

Important blood work• CBC w/ diff • Hgb and Hct• RBC incices

– Mean corpuscular volume (MCV), mean corpuscular hgb concentration (MCHC) and mean corpusuclar hgb (MCH)

• WBC indices – Basophils, eosinophils, monocytes, lymphocytes, neutrophils

(segmented and banded)

• ANC – (neutrophils x WBC count)= infection-fighting capacity (ANC >

1,000 = nml; ANC< 500= risk for infection)

• Chem 7• Others: BUN/ creat, Liver function tests, tumor markers

Clinical Therapy• Child managed by Pediatric Oncology Team• Therapy may be singular or combination

– Surgery– Chemotherapy (protocol-action plan for chemo)– Radiation – Biotherapy (antibodies developed to target tumor cells

for apoptosis; cancer vaccines)– HSCT (hematopoietic stem cell transplant)– Complementary therapies– Palliative care (presence of palliative care team)

FIGURE 29–4 Chemotherapy drugs either act at specific parts of the cell cycle or are nonspecific for action (act throughout all cell phases).




FIGURE 29–5 Chemotherapy protocol. A protocol is a map or plan of action that directs therapy by identifying the drug and its accompanying treatment.




Chemotherapy Side Effects

• Nausea/ Vomiting

• Alopecia

• Malaise

• Bone Marrow Depression– Infection– Bleeding– Anemia

• Stomatitis

Nursing Care Plan

• Based on type of cancer and therapy– Infection control– Pain– Nutrition– Growth and Development– Emotional– Spiritual

Three Types of Oncological Emergencies

• Oncologic emergencies result from the cancer itself or as a side effect of treatment.

• Most common emergencies are tumor lysis syndrome, septic shock, brain herniation, spinal cord compression, and superior vena cava compression.

• 3 Types of Oncological Emergencies:– Metabolic– Hematologic – Space-occupying lesions

Types of Oncological Emergencies

• Metabolic – Tumor lysis syndrome:

• Metabolic emergency results from lysis of tumor cells. This cell destruction releases high levels of uric acid, K+, and phosphates into the blood. Low levels of Na and Ca occur and metabolic acidosis results.

• Most commonly seen in Burkit’s lymphoma and ALL

• Tx: see table on pg 1049

Types of Oncologic Emergencies

• Metabolic – Septic Shock

• During period of immune suppression the child is vulnerable to overwhelming infection, resulting in circulatory failure, hypo/hyperthermia, tachypnea, mental changes, inadequate tissue perfusion, and hypotension

– Hypercalcemia• Elevated calcium in serum. • Occurs when large amounts of bone are destroyed by

treatment• Most common in children w/ ALL and rhabdomyosarcoma• Tx includes hydration and adequate intake of oral phosphate


• Hematologic:– Results from bone marrow suppression or

infiltration of brain and respiratory tissue w/ high numbers of leukemic blast cells (hyperleukocytosis)

– Bone marrow suppression results in anemia and thrombocytopenia

– This leads to coagulation problems and hemorrhage.


• Space-occupying lesions– Tumors w/ extensive growth that may result in

life-threatening situations (ie spinal cord compression, increased intracranial pressure, brain herniation, respiratory complications, etc.)

Nursing Management for a child with Cancer

• Nursing interventions focus on preventive teaching for all families about risk factors for cancer

• Health promotion and health maintenance of the child undergoing cancer treatment

• Carrying out treatment interventions• Managing health problems r/t both cancer and

the side effects of tx• Partnering w/ families to manage the challenging

psychosocial needs that emerge when cancer is diagnosed.

FIGURE 29–11 A vascular access device allows chemotherapeutic agents to be administered without the need for repeated “sticks” to the child.




FIGURE 29–6 (continued) A, The child with cancer depends on parents and family members to provide support. B, A special relationship often develops between the nurse and the child receiving treatment.




B

Nursing Assessment and Diagnosis

• Obtain a thorough history. Including:– Family hx of cancer– Hx of exposure to known carcinogens– Does parent work w/ chemicals/ asbestos– Was child tx’d w/ radiation/ chemo for cancer

previously– Does the child have any known conditions

such as Down’s syndrome– Any congenital anomalies

Nursing Assessment

• Physiologic Assessment– Includes possible s/sx of cancer or thorough

physical assessment if cancer already identified

• Psychosocial Assessment– Stress and coping– Knowledge– Support systems– Body Image

FIGURE 29–7 One of the most common threats to a child’s body image at any age is hair loss induced by chemotherapy. Use of hats can improve self-concept.




Nursing Assessment• Developmental Assessment

– Children under 6 should be regularly screened for developmental surveillance

– If changes in development are noted, or regression in milestones occurs during tx, refer to specialist

• Assessment for Impact of Cancer Survival– 1 in 1,000 young adults is survivor of childhood

cancer– Ongoing care is essential: long-term follow-up clinics– Help families manage long-term effects of cancer tx

Nursing Care of the hospitalized child with Cancer

• (Review Nursing care plans on pp 1057-1061)

• Planning and Implementation:– Ensure optimal nutritional intake

• 30% of children w/ cancer are malnourished• High metabolic rate of cancer depletes nutritional

stores• 24 hour dietary recall to assess nutritional intake• Antiemetic drugs to decrease N/V from chemo• w/ parenteral nutrition, weekly labs should be

performed including: chem 7, liver function studies and glucose

• Oral hygiene

Nursing care of the hospitalized child w/ cancer

• Planning and Implementation:– Administer Medication

• Most chemo drugs calculated based on child’s weight (dose/meter squared)

• Polypharmacy

– Manage Treatment side effects• Myelosuppression (suppression of blood cell prod)• Neutropenia (ANC < 500)

– Broad spectrum abx, G-CSF, isolation

Nursing Care of the Hospitalized Child with Cancer

• Planning and Implementation:– Ensure adequate hydration

• Strict I’s and O’s• Adequate hydration• IVFs

– Prevent and treat infection• Ensure standard precautions• Proper care of central lines• Teach parents infection control• Immunizations utd

Nursing Care of the Hospitalized Child with Cancer

• Planning and Implementation:– Manage Pain ***

• From disease and medical interventions• Incorporate Pain management team when possible• Conscious sedation for some procedures (ie LPs)• Topical anesthetics (EMLA creams) for IV access• Group painful procedures during sedation when

possible (ie LP and Port access)• Include parents/family, when possible to comfort

child

FIGURE 29–10 A child in a pediatric oncology clinic giving injections to a doll. This type of play therapy helps the child deal with fear, thus lowering his or her stress level.




Nursing care of the Hospitalized Child with Cancer

• Planning and Implementation:– Provide Psychosocial Support

• To child and family

– Care in the Community• Assist family in preparation for home therapy

– Health Promotion/ Health Maintenance• Treatment is often a long process (2-3 years)• Still important to have health maintenance visits

during this time

Leukemia

• Most commonly diagnosed malignancy in children under 14

• Cancer of the blood or bone marrow, characterized by an abnormal proliferation of blood cells, usually wbc’s.

Childhood Leukemia• Acute Lymphocytic Leukemia (ALL) 75% of all

leukemias in children– Peak age of onset is 2-4 years– 90-95% of children w/ ALL will achieve a 1st remission– Almost 80% will live 5 years– Rapid proliferation of immature blood cells which

makes the bone marrow unable to produce healthy blood cells

• Acute nonlymphocytic (ANLL) or Acute Myelomonocytic leukemia – Most common in children under 2 y.o and adolescents– 17% of all leukemias; 50-70% of adolescents achieve

a 1st remission– 40% live 5 years

Leukemia • The cause…

– Exact cause of most leukemias remains unknown

– Increasing evidence suggests a combination of contributing factors

– Predisposing factors• Familial tendency• Monozygotic twin w/ leukemia• Congenital disorders, such as Down’s, AT• Viruses • Ionizing radiation• Exposure to the chemical benzene and cytotoxins

such as alkylating agents

Pathophysiology of Leukemia• WBCs are produced so rapidly that immature

cells (blast cells) are released into circulation• Blast cells multiply continuously w/o respect to

the body’s needs• Blast cells may be as high as 95% in the bone

marrow (nml= <5%)• Increased proliferation of WBCs robs healthy

cells of nutrition• Bone marrow undergoes hypertrophy (can lead

to fxs)• Bone marrow then undergoes atrophy, leading

to anemia, bleeding disorders, and immunosuppression

Leukemia• Clinical Manifestations:

– High fever– Thrombocytopenia– Abdominal or bone pain– Pallor, chills, and recurrent infections– Petechiae and ecchymosis– Abnormal bleeding, (nosebleeds, wounds, and oral

lesions– Confusion, lethargy, and HA if the blood-brain barrier

has been crossed– Fatigue– Painless lumps in neck, underarm, stomach and groin

Diagnostic Test findings in Leukemia

• Bone marrow biopsy confirms dx:– aspirate showing a proliferation of immature

WBCs (>25% blasts)

• Blood counts show thrombocytopenia, neutropenia, and anemia

• Differential leukocyte count determines cell type

• LP detects meningeal involvement (if CNS involved)

• Cytogenetic analysis shows a “Philadelphia chromosome” in ALL

Treatment of Leukemia

• Systemic chemo aims to eradicate leukemic cells and induce remission

• Intrathecal chemo to prevent or tx CNS infiltration

• Abx, antifungal and antiviral drugs and granulocyte injections to control infection

• Transfusions of plts to prevent bleeding and of RBCs to prevent anemia

• Bone marrow transplant

Nursing Interventions • Prevent infection (private room, oral hygiene,

screen visitors for infections)• Inspect skin frequently (avoid rectal meds,

temps)• Give increased fluids to flush chemo through

kidneys• Provide pain relief• Monitor CNS for involvement• Group nursing interventions• Help child adjust to changes in body image

Soft Tissue Tumors• Hodgkin’s Disease

– Disorder of the lymphoid system– Usually arises from a single or group of lymph

nodes– Incidence: 3/100,000; peaks in adolescent

boys– Clinical Manifestations include: main sx= a

nontender, firm lymphadenopathy, fever, night sweats, weight loss

– Prognosis excellent: Tx based on staging: 5 year survival 90%

FIGURE 29–15 Lymph nodes and organs affected in Hodgkin disease in children.




Soft tissue tumors

• Non-Hodgkin’s Lymphoma– 3 types:

• Lymphoblastic Lymphoma (30-40%)• Small noncleaved cell (Burkit’s) Lymphoma (40-

50%)• Large cell Lymphoma (15%)

– Malignant tumors of lymphoreticular (internal framework of the lymph sx) origin

– Peak incidence b/t 7-11 y.o; 3X more common in boys

Soft Tissue Tumors

• Non-Hodgkin’s Lymphoma– Clinical Manifestations include: enlarged

lymph glands usually in the axillary, cervical, inguinal and femoral nodes.

– Tx based on type and staging

Any Questions….Let’s do a case study!!




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Kristine Ruggiero CPNP, MSN, RN Chapter 29 Alterations in Cellular Growth